Medical Screening of Mental Health Patients in the Emergency Department: A Systematic Review

Chennapan, Krithika; Mullinax, Samuel; Anderson, Elaine A.; Landau, Mark J.; Nordstrom, Kimberly; Seupaul, Rawle A.; Wilson, Michael P.

doi:10.1016/j.jemermed.2018.09.014

Cited by 22 publications

(7 citation statements)

References 60 publications

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“…-Inatención a los signos vitales u omisión de obtenerlos -Examen físico omitido o deficiente -Diagnóstico diferencial incompleto, basado en datos parciales -Adopción precoz de hipótesis diagnóstica sesgada (diagnóstico psiquiátrico primario) -Solicitud inadecuada de exámenes auxiliares ("escopeta de perdigones") -Reducirlo a un proceso transversal y no con evaluaciones reiteradas mientras sea pertinente Modificado a partir de (10) Rev Neuropsiquiatr. 2021; 84(1): 51-57 contribuyendo significativamente a la molestia psicopatológica motivo de atención (8). El término ha sido criticado pues da a entender un proceso inmediato y estático, no dinámico, al asumir a un paciente como "medicamente limpio" de patología orgánica (9); de hecho, es una recomendación importante que en ocasiones se establezca un periodo de observación para definir mejor los síntomas y afinar el diagnóstico (10).…”

Section: Discussionunclassified

“…No existe consenso respecto a qué exámenes o procedimientos auxiliares deban siempre considerarse dentro del proceso de "medical clearance", circulan diferentes guías de práctica clínica y artículos de revisión al respecto, con posturas incluso divergentes (8). Eso, sin tener en cuenta que estos procesos pueden corresponder a emergencias médicas generales o a emergencias psiquiátricas (donde no existe un médico internista permanente y usualmente no hay laboratorio clínico ni gabinete de imagenología disponible) y, en ocasiones, el "medical clearance" también se refiere a la exclusión de patologías médicas antes de la hospitalización de un paciente en el pabellón de internamiento, sin tratarse específicamente de un caso de emergencia.…”

Section: Discussionunclassified

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Covid-19 y cetoacidosis diabética erróneamente diagnosticadas como ansiedad primaria: Reporte de un caso acerca de causas médicas versus psiquiátricas de ansiedad.

2021

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Los trastornos de ansiedad tienen gran importancia en la psiquiatría de urgencias, tanto por la frecuencia con la que se presentan, como por la relevancia de las enfermedades somáticas que pueden subyacer a un cuadro ansioso. Resulta imperativo determinar desde el abordaje diagnóstico inicial si los signos y síntomas de la ansiedad constituyen una plena respuesta a situaciones de estrés, son manifestaciones de una patología somática subyacente, o se pueden explicar como síntomas de un trastorno psiquiátrico primario específico. En el momento actual, la pandemia de COVID-19 –en la que el Perú ha llegado a tener la mayor tasa de mortalidad mundial-- desborda los servicios de salud con abigarrados cuadros en los que se combinan tanto los síntomas de la infección viral por sí misma, como los de reacciones ansiosas y respuestas al estrés. A propósito de un caso ilustrativo, en el que el proceso de tamizaje médico fue deficitario y se etiquetó al paciente como un caso primario de “ansiedad”, con un desenlace lamentablemente ominoso, se revisa brevemente la literatura acerca del proceso de medical clearance (o descarte de condiciones médicas) y se reafirma concluyentemente la importancia de una consideración diagnóstica inicial abarcadora, no sesgada, y basada en criterios clínicos sólidamente elaborados y sustentados. Es evidente, por otro lado, que el psiquiatra requiere estar permanentemente actualizado sobre las formas de presentación psicopatológica asociadas a la sintomatología de COVID-19.

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Section: Discussionunclassified

Covid-19 y cetoacidosis diabética erróneamente diagnosticadas como ansiedad primaria: Reporte de un caso acerca de causas médicas versus psiquiátricas de ansiedad.

2021

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“…Although the use of a triage algorithm for psychiatric screening to expedite medical clearance and reduce unnecessary pathology tests has been suggested, 21 the opportunity to reduce ED‐LOS likely exists mostly for patients with a known MHD according to a recent systematic review 22 . For these patients with an exacerbation of their MHD, a targeted physical examination and an assessment of mental state can usually suffice, without the need for urine toxicology or pathology testing 22 . Likewise, ACEP recommends brain imaging only for those adults with new‐onset of psychosis and with a focal neurologic deficit, in the absence of other risk factors 7…”

Section: Discussionmentioning

confidence: 99%

Patients with mental health conditions in the emergency department: Why so long a wait?

Sweeny

Keijzers

O’Dwyer

et al. 2020

Emerg Medicine Australasia

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Objectives: Patients presenting with a mental health disorder (MHD) wait longer in the ED compared to those presenting for other reasons, potentially placing vulnerable patients at further risk for deterioration. The present study identified factors associated with a long ED stay for patients with a MHD. Methods: Linked ambulance, emergency, pathology, imaging and admission data for an 18-month period were analysed for ED presentations diagnosed with an MHD ICD-10 at a large teaching hospital. Admissions and discharges were considered separately; a long ED stay was defined as the 90th percentile length of stay. Multivariable generalised linear models were built, identifying predictors of a long ED stay for presentations diagnosed with a MHD. Results: The sample comprised 1163 admissions and 2242 discharges. For admissions, significant predictors for long ED stay were investigations (pathology or imaging tests), a triage score of 1 or 2, arrival out-of-hours (18.00-05.59 hours) and arrival by ambulance. For discharges, significant predictors of a long ED stay were investigations (pathology or imaging tests), arrival out-of-hours, arrival by ambulance and increasing age. Conclusions: Some factors predictive of a long ED stay for patients presenting to the ED and diagnosed with a MHD varied based on their disposition. For admissions, the most urgent presentations were likely to stay longest. Strategies to reduce ED stay for both admissions and discharges should consider addressing modifiable aspects, including the need for certain investigations, and nonmodifiable aspects, including the need for further access to afterhours mental health services in hospital and in the community.

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“…Systematic reviews have found that routine blood tests rarely alter the management of patients due for admission to psychiatric hospital, even when abnormal results are found. 6 , 7 In one of the included studies of 500 patients, only one individual had an abnormal result that mandated urgent medical intervention. Notably, this patient was obviously symptomatic.…”

Section: The Case For Not Investigatingmentioning

confidence: 99%

Psychiatrists should investigate their patients less

et al. 2021

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Summary Psychiatrists often order investigations such as blood tests, neuroimaging and electroencephalograms for their patients. Rationales include ruling out ‘organic’ causes of psychiatric presentations, providing baseline parameters before starting psychotropic medications, and screening for general cardiometabolic health. Hospital protocols often recommend an extensive panel of blood tests on admission to a psychiatric ward. In this Against the Stream article, we argue that many of these investigations are at best useless and at worst harmful: the yield of positive findings that change clinical management is extremely low; special investigations are a poor substitute for a targeted history and examination; and incidental findings may cause anxiety and further unwarranted investigation. Cognitive and cultural reasons why over-investigation continues are discussed. We conclude by encouraging a more targeted approach guided by a thorough bedside clinical assessment.

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Medical Screening of Mental Health Patients in the Emergency Department: A Systematic Review

Cited by 22 publications

References 60 publications

Covid-19 y cetoacidosis diabética erróneamente diagnosticadas como ansiedad primaria: Reporte de un caso acerca de causas médicas versus psiquiátricas de ansiedad.

Covid-19 y cetoacidosis diabética erróneamente diagnosticadas como ansiedad primaria: Reporte de un caso acerca de causas médicas versus psiquiátricas de ansiedad.

Patients with mental health conditions in the emergency department: Why so long a wait?

Psychiatrists should investigate their patients less

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